Obstetrics in Uganda
Physicians and nurses demonstrate a commitment to care in the face of limited resources.
By James R. Woods, M.D.
She lay on the cold examination table fully dilated and pushing. No sheet. No anesthesia. Only our visiting team of obstetricians, one of their University midwives, and a warmer constructed of a flat board above which were four light bulbs awaiting the birth of the newborn. This was my introduction to obstetrics at the Mbarara University of Science and Technology (MUST) in Uganda—restricted resources, but heroic commitment.
Uganda is a poor country of 30 million about the size of Oregon. English is spoken widely, and the country is about 90 percent Christian. Uganda is poor, but there are 10 million cell phones and a rapidly expanding Internet system. I went to Uganda to develop global long-distance learning in obstetrics.
My motivation was to create obstetric learning centers in Uganda for Peri-FACTs, my 20 year old Internet journal. We had already established physician and nurse users in more than 600 hospitals in the United States, and a small cadre of users in Ethiopia, Saudi Arabia and the Seychelles Islands when I reunited with Leo Lagasse, past chief of gynecologic oncology at UCLA and his six physician and nurse team. For 15 years, Dr. Lagasse has been president of Medicine for Humanity, a non-profit organization committed to advancing the health of mothers and babies.
Their activities had taken them to many Third World countries, but lately they have focused on Uganda and the training of residents in fistula repairs. Several years back, a UCLA resident chose to go to Mbarara to learn to do fistula repairs. Since more than 60 percent of all obstetric deliveries in the western region of Uganda occur at the hands of a family member at home, sometimes two or three days travel from a hospital, obstructed labor or fetal malposition often produce not only fetal distress or death, but also maternal vescovaginal fistulas, resulting in constant urine loss and smell leading to social ostracism.
When the word would got out that an American team of gynecological surgeons was coming for a couple of weeks to repair fistulas, it was no suprise that families would travel for days to be evaluated, and hopefully chosen to be one of the lucky surgical patients. Surgeons in each operating room would be busy day after day, but if the fistulas required more extensive repair including placement of a mesh, the patient was turned away.
My role as a perinatologist was more as a teacher of how Peri-FACTs might provide sustainable obstetric education for the faculty, nurses and residents. Toward that end, I met Dr. Ivan Bonet, perinatologist and chairman of the University obstetrics and gynecology program. He is one of four Cubans who rotate that position every two years. He immediately recognized Peri-FACTs as a valued addition to his resident education curriculum. The seven faculty members consist largely of graduates of their residency programs. There are currently 11 residents.
In communities like Mbarara, the families bear much of the responsibility for the clinical outcomes. Some medications are available in the hospital, such as oxytocin. For most other medications, families must go to a pharmacy, buy the medications, and then bring them to the hospital.
At the University hospital there are more than 7,000 babies delivered each year, with 75 percent of deliveries performed by 16 midwives. The hospital quotes a 30 percent cesarean section rate. An old ultrasound machine is available, signifying evidence of a more modern obstetric era. One fetal monitor is present, but with 7,000 deliveries, seldom used. One bed is used for obstetric postpartum ICU patients, and IV poles are available to hang bags of IV fluid into which medications are injected through the plastic outer walls.
Limited medical resources at the University mandate a level of clinical care resembling that in the U.S. around 1973. Absent the availability of equipment on a predictable daily level, there is no place for laparoscopic or robotic equipment, or genetic procedures. Respiratory support equipment for the very premature newborn is absent.
Lack of newborn ventilators means that if a baby delivers before 35 weeks gestation, he or she needs to be hardy, because there are no means to support the ventilator challenges of a more premature baby. Cesarean sections, therefore, are seldom done before 35 weeks because of the lack of newborn support systems.
In the building where gynecological surgery is going on all day, a scalpel, clamps, scissors and sutures are all that can be counted on to be available. At this University hospital, electricity usually is available. However, one day all the electricity went out, a not unusual occurrence I later learned, and generators were not working. Elective surgery was cancelled, but cesarean sections were still being done upstairs in one of the surgical theaters by the light of a window.
The greatest maternal risks are eclampsia, hemorrhage, ruptured uterus and infection. Eclamptic seizures and ruptured uteri in large part occur at home before the patients are able to get to the hospital. Thousands of maternal deaths were the norm more than 10 years ago, even at this University hospital. But with better education of families, encouraging them to travel to the hospital for their deliveries, maternal mortality was reduced to 56 deaths two years ago, and 32 deaths last year. More significant, no maternal deaths occurred last year if a patient was able to reach the University hospital prior to delivery. Clearly, educating families about the value of hospital care and eliminating the cultural obstacles creating fear of institutional medicine have made a difference.
Impressive clinical knowledge
The woman lucky enough to have a hospital delivery literally moves with her family onto the hospital grounds a couple of weeks before her due date to camp out on a small rug. When labor starts, the woman remains outside the obstetric building until she is deemed to be at least 4 cm dilated. She then is allowed into the antepartum unit.
When she is fully dilated, she is brought into a delivery room with two examination tables, where, if she does not deliver inside of 30 minutes, a large mediolateral episiotomy is cut and the baby is delivered either spontaneously or by vacuum. Why the rush? Because of the large number of women waiting either just outside the building or inside in the antepartum section.
I was impressed by the clinical knowledge demonstrated by the University faculty and residents. Each morning, faculty and residents review all obstetric and gynecology cases occurring through the night, after which clinical assignments are handed out. One night, we conducted journal club with their faculty and residents, discussing two articles regarding IUD contraception from a recent issue of Obstetrics and Gynecology. Their use of statistics and clinical concepts meshed with our own. The next day, we taught their medical students, who by sheer exposure and practice, were comfortable to discuss procedures, complications and ob/gyn risks.
The medical student teaching session was held in their University simulation skills lab where, with a mannequin, we reviewed shoulder dystocia, breech delivery and also observed one instructor using a beef heart as a simulated uterus to demonstrate how to perform and repair a transverse uterine Incision. Since these University students are often thrown into many clinical situations not available to our own students, it is no surprise that these students on practical issues were confident and well prepared.
My goal of establishing Peri-FACTs learning centers in Uganda was successful. But what truly stayed with me was my utter respect for these medical colleagues, working with such limited resources, never complaining, and yet driven to offer the best medical care that they could. I also could not ignore the question that kept running around in my mind. Since 1973, with all the increased dollars spent on health care in the United States, has this spending spree brought a proportional increase in our health care outcomes?
James R. Woods, Jr., MD is the Henry A. Thiede Professor and chair of the Department of Obstetrics and Gynecology at the University of Rochester Medical Center.
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